Intrapartum Nursing Assessment

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NurseFaith
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Intrapartum Nursing Assessment
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2014-10-06 22:50:37
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Intrapartum Nursing Assessment
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  1. Emotional Support for the Laboring Woman:
    • Establish Therapeutic Relationship
    • Continued presence and Eye Contact
    • Reassurance and Praise
    • *Be an advocate for her! (ie: privacy- tell dr)
    • *ascertain what she expects for the experience...formulate birth plan and cultural beliefs
  2. Labor progress info and advice for the Laboring Woman:
    Explain commonly used terms and procedures
  3. Comfort Measures for the Laboring Woman:
    Relaxation techniques, promote hydration, massage and position changes
  4. Advocacy for the Laboring Woman:
    Assisting to articulate the patient's wishes to others

    Birth plan review
  5. An Admission Assessment for the Laboring Woman consists of:
    Comprehensive review of prenatal records and lab results

    • Ascertain Pts plans for childbirth
    •    (support person, who she calls family)
    •    (ask who will be at delivery)
    •    (cultural or religious preferences)
    •    (plans for discomfort or pain management)
    •    (plans for infant feeding: breast/bottle)
    •    (plans for circumcision)

    *unless specifically said in the question on exam, always assume she is low risk
  6. Prenatal Record Review Consists of:
    EDD/EDC and last menstrual period

    Prior obstetrical hx (total number of preg, births, miscarriages, living children)...document their Para (TPAL= term, preterm, abortion, living)

    Type of deliveries she's had (NSVD or C section)

    Lab results

    Ultrasounds (noting confirmed and placental location)

    OB office visits and notes (V/S trends, urine dip results, pregnancy complications, weight gain trends)

    Medication hx

    Allergy Hx
  7. History components of the prenatal record review consists of:
    Current pregnancy history (TPAL, no complications, began prenatal care ___, total wt gain ___)

    Past OB Hx (SVD at ___wks, wt of baby, etc)

    Past medical history and surgical history

    Family History

    Social (Denies hx of ETOH, smoking, substance abuse, denies domestic violence)....if suspected drug use, call for urine drug screen, advocate for baby!!!
  8. Labs and Ultrasounds that are important to review in prenatal record:
    Blood Type and Antibody Screen (Rh neg, any Rhogham?)

    Hgb/Hct- checking for anemia

    Plt status

    Group B strep- pos or neg

    HIV status

    Hep B status

    1 Hour GTT results (130-145)

    Rubella immunity status- immune/nonimmune or equivocal (more info)

    Any STD hx or recent tx: herpes, chlamydia, etc

    Ultrasounds: dating (1st trimester) and anatomy scan ultrasound done at 18-20 weeks (2nd trimester)
  9. What should be done to pt chart if mom denies HIV testing?
    Make not in her chart! She can refuse to have it taken, but we don't need permission to test the baby
  10. What do we do for a laboring woman positive for Herpes?
    Put her on suppression therapy (35-36 weeks) to help prevent infecting baby during delivery...if mom doesn't do therapy, C-Sec will be necessary
  11. Focused Admission "Maternal and Fetal Well-Being" Assessment:
    *Mother/Baby wellbeing overall is priority before paperwork!!!

    • Time of Labor Onset:
    • -When did contractions begin?
    • -Current frequency, duration and intensity of contractions

    Status of Amniotic Membranes

    • Ask woman about:
    • -fluid leakage?
    • -bloody show/bleeding?
    • -fetal movement?
    • -allergies?
    • -quick OB hx, EGA?

    • Perform on Arrival: (prn)
    • -maternal vs
    • -ultrasound and FHR monitor
    • -toco transducer
    • -vaginal exam if labor suspected as advanced
  12. If a woman comes in with the water broken, monitor her temp:
    every 2 hours
  13. Maternal Physical Exam during Admission Assessment:
    Heart, Lungs, skin, Edema (put grade!), DTRs, clonus and emotional status

    *palpate abdomen intensity, resting tone

    *place toco to monitor UCs (assess freq, duration, and length)

    Assess for vaginal bleeding and amniotic fluid status (amount and characteristics)
  14. ONLY perform SVE (sterile vaginal exam):
    if clinically indicated! puts mom and baby at risk each time- especially if water is broken
  15. Fetal Exam during Admission Assessment:
    Ultrasound Transducer (EFM) placement

    Assess fetal heart tones by EFM (baseline, variability, and presence or not of accels and decels)

    Doppler Auscultation

    Palpate maternal abdomen (fetal position via leopold maneuver)
  16. Admission Medical Interventions often ordered:
    IV or saline lock access

    Continuous EFM or Intermittent EFM and Toco

    Lab tests (CBC, Blood type (& hold in case of P-P hemorrhage), possible urinalysis and drug screen)

    Diet orders (clear liquids or ice chips- if epidural plan)

    IV antibiotics (if GBS pos= penicillin!!! 4 hours must elapse after hanging bag  so infection can be cleared before delivery...rectovaginal swab to assess)
  17. Determin which fetal part is located in the uterine fundus by performing:
    • Leopold's 1st Maneuver
    • (face the patient)
  18. Determine the location of the fetal back by palpating hard down the uterine sides and using:
    • Leopold's 2nd Maneuver
    • (palpate softly over body parts)
  19. To determine the presenting part of the baby, perform ____ by palpating the suprapubic region then attempt to grasp presenting part between thumb and index finger
    Leopold's 3rd Maneuver
  20. If the baby's presenting part is "Engaged":
    The RN will be UNABLE to move head back and forth
  21. To determine the location of the cephalic (VERTEX), perform ___ by facing pt feet and sliding fingers to upper edge of pubic bone feeling for cephalic prominence:
    Leopold's 4th Maneuver
  22. Types of External Monitoring Transducers:
    Tocotransducer (top belt and monitor-- monitors UCs at fundus)

    Ultrasound Transducer/Electronic fetal monitor (EFM) -- lower belt and monitors FHR
  23. Any High Risk/ Fetal Risk/ Decelerations / Low fluid / Comorbidities require:
    Continuous monitoring!!!! (Doppler and toco)
  24. Why is monitoring FHR duing labor so important?
    FHR responds to multiple physiological factors:

    Uteroplacental Exchange (increased CO, Uterine arteries deliver oxygenated blood via relaxation of uterus in between UCs)

    Fetal Circulation via the umbilical vein and arteries

    *not necessarily what happens during labor, but what happens to them after (cardio demand)

    • FHR increases during fetal movement
    • FHR slower and less variability during sleep
  25. Fetal Environmental Factors affecting O2 of Fetus:
    Uterine Activity- prolonged/too frequent UCs

    Utero placental insufficiency risk factors- preg induced hypertension/pre-eclampsia and GDM

    Maternal Physiological Function Issues- post epidural placement or supine hypotension, abruptio placentae (hemorrhage)

    Umbilical Cord Issues- compression of cord, prolapse of cord
  26. "Normal UCs" during labor:
    < 5 UCs in 10 minutes, averaged over 30 min window
  27. Tachysystole (uterine hyperstimulation) is indicated in labor by:
    >5 UCs in 10 min over 30 min window
  28. On admission, a fetal strip over how long is taken to obtain a baseline FHR strip, ...evaluation needed if ambulating with intermittent EFM
    20-30 minutes
  29. Fetal Heart Rate Assessment Time Intervals:
    Admission: 20-30 min

    • First Stage Labor:
    •   -Latent/Early: q30-60min
    •   -Active Labor: q15-30 min
    •   -Transition: q15 min

    • Second Stage Labor: (pushing)
    •   -after each contraction...usually on continuous monitoring during this phase
  30. In the presence of maternal or fetal risk factors, or signs of fetal distress, the EFM is:
    CONTINUOUS
  31. Normal FHR
    110-160
  32. Average FHR over 10 min, rounded to nearest 5bpm
    FHR baseline
  33. True Tachy has to be sustained FHR > ?
    160 over a ten minute period
  34. Periodic or episodic changes interpretations on
    monitor
    • Accelerations
    • Decelerations
  35. _____ are predictive of adequate fetal oxygenation and absence of fetal acidemia
    Accelerations
  36. Accelerations are categorized by:
    • 15 beats above baseline and lasts 15 seconds
    • (15:15 rule)
  37. Amplitude range >25 bpm
    "Marked" amplitude
  38. Amplitude from peak 6 bpm-25 bpm
    Moderate Amplitude (predicts fetal wellbeing)
  39. Amplitude range undetectable <5 bpm
    Minimal amplitude
  40. Amplitude range undetectable
    Absent amplitude
  41. Minimal and Absent amplitude in FHR can be due to:
    Fetal Sleep, Maternal Sedation with meds or indication of fetal CNS injury
    • Hard to determine baseline….you
    • still have to try to determine HR  (draw
    • an imaginary line through the middle)

    • If this is sustained, you would need to find out what is going on…the baby is trying to
    • overcompensate for something that is about to happen…

    Little patterns of this are okay because baby could just be excited
  42. Variability that is an indication of GOOD!
    Moderate Variability (6-25bpm)
  43. Maternal Causes of Fetal Bradycardia (<110 for > 10 min)
    • Supine Hypotension
    • Dehydration
    • Acute maternal cardiac event or seizures
    • Ruptured uterus
    • Placental abruption
    • Medications: anesthetics
  44. Fetal Causes of Fetal Bradycardia (<110 for >10 min)
    • Fetal response to hypoxia
    • Umbilical cord compression
    • Profound Hypoxemia
    • Hypokalemia
    • Chronic fetal head compression
    • Fetal Bradyarrythmias
  45. Maternal causes of Fetal Tachycardia (>160 for >10 min)
    • FEVER
    • Infection- GBS, Chorioamnionitis
    • Dehydration
    • Anxiety
    • Anemia
    • Medications: stimulants, epinephrine, ADHD meds
    • Illicit Drugs: cocaine (leads to abruption)
  46. Fetal Causes of Fetal Tachycardia:
    • Infection/Sepsis
    • Fetal Increased Activity
    • Compensatory or chronic hypoxemia
    • Fetal Tachyarrhythmia
    • Fetal Anemia
    • Fetal Cardiac Anomalies
  47. Transitory decreases in the FHR baseline
    Decelerations
  48. Decelerations are assessed by:
    Shape, Timing, and Duration in relation to the contraction

    • Intermittent: occur <50% over 20 min
    • Recurrent: occur >50% over 20 min
  49. Early Decelerations typically mean:
    Head Compression
  50. Late decelerations happen at the ___ as the contraction is already trying to relax
    Nadir (PEAK)
  51. In early decelerations, the nadir matches:
    • peak of contraction...mirrors the conctraction
    • (>30sec)
  52. Cause of Early Decelerations:
    Head Compression related to contraction

    (benign, no intervention)
  53. Interventions for variable decelerations
    positioning, fluids, oxygen flow (10L/min facemask), internal monitors
  54. Cause of Variable decelerations:
    Umbilical Cord Compression

    (sudden fetal head descent in labor-- call rapid response!!!!)
  55. Most common type of decelerations
    Variable Decelerations
  56. Shape of Variable Decels
    U, W, or V
  57. Most variable decelerations last ______, and have a rapid baseline return
    <60 sec
  58. Abnormal variable decelerations: persistent deep variables, prolonged baseline return, repetitive variables with absent variability
    Severe Variable Decelerations
  59. Severe Variable Decelerations have depth below ____bpm and duration longer than ____
    70 bpm... 1 minute

    *persistent variable decelerations may lead to acidosis and fetal distress...Immediate delivery if they do no stop!!!
  60. Prolonged Decels are categorized by
    >15 bpm and > 2 min but <10min

    Visually apparent decrease, "Drop" in baseline

    (not a true brady, but will eventually result in bradycardia if you can't control it)
  61. Drug given (also used in preterm labor to stop contractions) for prolonged deceleration
    Torbutaline
  62. Etiology of Prolonged Decelerations
    • Cord Compression
    • Maternal Hypotension
    • Uterine Tachysystole
    • Maternal Hypoxia
    • Rapid Fetal Descent
    • Pelvic Exam: SVE or application of FSE
  63. When the fetal heart rate lags behind contractions with little or no variability in line
    Late decelerations with variability loss (persistant late decels associated with decreased variability are ominous signs)
  64. When does the "nadir" occur in late decelerations?
    AFTER peak of UC...
  65. Which NICHD Category are FHR tracings normal "strongly" predictive of normal acid- base status at the time of observation
    Category 1 (reassuring)
  66. Which NICHD categoryis when FHR tracings are indeterminate-- lack of adequate evidence to classify as normal or abnormal
    Category 2
  67. Which NICHD category are FHR abnormal-- predictibe of abnormal fetal acid base status at the time of observation
    Category 3 (not reassuring)...fetus needs to come out ASAP
  68. Category 1 (normal) NICHD:
    • Baseline 110-160
    • Moderate variability
    • Accels absent or present (as long as moderate varibility is present, accels are just a plus)
    • Late or variable decels are ABSENT
    • Early decels are absent or present (benign)
  69. sometimes early decels can mean:
    soon to deliver :)
  70. CATEGORY 2 NICHD
    may include both reassuring and nonreassuring components

    • Bradycardia without absent variability
    • Tachycardia
    • Baseline variability (marked, minimal, absent...without decels)
    • Decelerations (prolonged, variable decels with slow baseline return)

    • *needs more research evidence to clarify appropriate intervention
    • *Use additional assessment methods to clarify fetal oxygenation status (FSE placement)
  71. If you have Bradycardia AND absent variability, this is considered category:
    3
  72. Category 3 NICHD
    Absent baseline FHR variability with any of following:

    • Recurrent late decels
    • Recurrent variable decels
    • Bradycarida
    • Sinusoidal pattern: Smooth, Saw-tooth pattern in FHR baseline; usually lasts 3-5 min for 20 min
  73. Interventions for Categories 2 and 3: (for repetitive decel pattern)
    Correct any underlying prob (ie: maternal hypotension -> give ephedrine prn)

    Maternal Reposition- lateral position to prevent cord compression

    IV fluid bolus- approx 500ml lactacted ringers; increase fluid volume and improve uteroplacental perfusion

    Oxygenation- via facemask at 10L/min, improve fetal O2 status

    Notify midwife/MD: perform SVE if indicated, monitors and possible amnioinfusion

    Reduce UC activity: stop pitocin, administer terbutaline (relaxes uterus)
  74. A sterile vagnial exam consists of:
    Assessment of cervical dilation, effacement, and fetal station (labor process and appropriate options for labor medication use)

    Determines fetal presentation, station, and position

    Evaluate rupture of membranes (ROM)

    Performed ONLY when necessary

    Sterile gloves and lubricant using 2 fingers

    *Rule out cord prolapse due to FHR indications
  75. If a fetal scalp stimulation (gloved digital stimulation/tickling) produces a reassuring acceleration (15 x 15), it indicates:
    Normal fetal oxygenation and acid-base balance
  76. Clear, Yellowish fluid that surrounds and protects the fetus in uterus
    Amniotic Fluid
  77. Always assess the amniotic fluid for:
    Color, Amount (small, mod, heavy), Odor
  78. Normal Amniotic fluid should be:
    • Clear, cloudy, thin/watery
    • Odorless usually or may have musty smell
  79. Abnormal amniotic fluid will be:
    • Meconium stained (fetal stool in fluid)
    • Yellowish, greenish brown or brown
    • Port-wine stained -> possible abruption
    • Foul Odor or malodorous
  80. Who should always be on hand if abnormal amniotic fluid presents:
    Respiratory Team (baby at risk for aspiration)
  81. Amniotic fluid is ____ while vaginal fluid is ___ (pH scale)
    Alkalinic; Acidic
  82. When the yellow paper from an amniotic fluid status test with nitrazine paper turns BLUE , it means:
    Positive amniotic fluid rupture!
  83. Under a microscope, amniotic fluid will have:
    a "ferning" pattern
  84. Artifical rupture of the membranes (AROM)
    Amniotomy Procedure (using an amnio-hook)
  85. Rapid and non-invasive immunoassay test that does NOT require speculum; it is inserted inside vagina by RN or provider... (99% accurate for diagnosed ROM)
    AmniSure Test
  86. 2 types of Internal Fetal Monitoring:
    Fetal scalp electrode (internal fetal heart monitor)

    Intrauterine pressure cath (IUPC)-- internal contraction monitor
  87. Invasive procedure by provider, applied directly to fetal presenting part to detect FHR
    Internal Fetal Scalp Electrode (FSE)
  88. Interventions for Internal Fetal Scalp Electrode:
    continuous monitoring and direct fetal monitoring; rupture of membranes needed
  89. If a mom has HIV, Hep B or any other major virus, do not use _____ to assess FHR bc of risk of transmission
    FSE (internal fetal scalp electrode)
  90. Invasive procedure done by provider into the cervix and uterine cavity to detect actual frequency, duration and strength along with resting tone
    Intra Uterine Pressure Catheter (IUPC)
  91. Streptococcus Agalactaie -- can cause both infant morbidity and mortality
    Group Beta Strep (GBS)
  92. What percentage of pregnancies colonize GBS
    10-30%
  93. GBS is Tested for at ____ weeks gestation
    35-36
  94. Drug of choice for GBS
    • Penicillin or Ampicillin
    • (implemented in 1990s and reduced early onset of neonatal sepsis by 80%)
  95. Room temperature saline infusion via IUPC into uterus
    Amnioinfusion
  96. What does an amnioinfusion do?
    Increases fluid to cushion the umbilical cord and reduce cord compression; used to treat recurrent variable decels due to decreased amniotic fluid
  97. Intrapartum Prophylaxis for GBS: (per CDC guidelines in 2010)
    Positive Statuse noted on recto-vaginal swab

    Previous Infant with invasive GBS

    Unknown GBS status <37 weeks gestation

    Maternal temp >100.4 or ROM >18-24 hours depending on hospital

    GBS positive urine infection or noted in urine earlier in pregnancy

    *GOAL= IV administration of Penicillin (PCN) started at least 4 hours before delivery
  98. Theory: Sensation of pain is transmitted from the periphery of body along ascending nerve pathways to the brain...based on the premise: pressure application to certain areas of the body can limit pain
    • Gate Control Theory of Pain
    • (pressure point massage)
  99. Cutaneous stimulation with gentle downward stroking of abdomen
    Effleurage
  100. Non Pharmacological Management of Labor
    Labor Support Presence: sinificant other/spouse, family members, friends, nurse, midwife, doula

    Child birth classes (lamaze hypnobirthing, Bradley methods)

    Cognitive/Mental stimulation (attention focusing, focal point, guided imagery, music)

    Breathing/Relaxation techniques

    Effleurage, Counter Pressure and Back Massage

    Thermal stimulation: cold/hot therapy
  101. Complementary Therapy
    Aromatherapy, Soothing voice with massage, Birthing Ball, Hydrotherapy: standing in shower or water-birthing

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